NORTH TYNESIDE URGENT AND EMERGENCY CARE STRATEGY 2014 - 2019 - North Tyneside Urgent Care Working Group

 
NORTH TYNESIDE URGENT AND EMERGENCY CARE STRATEGY 2014 - 2019 - North Tyneside Urgent Care Working Group
North Tyneside
Urgent Care Working Group

      NORTH TYNESIDE
       URGENT AND
     EMERGENCY CARE
        STRATEGY
             2014 – 2019

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NORTH TYNESIDE URGENT AND EMERGENCY CARE STRATEGY 2014 - 2019 - North Tyneside Urgent Care Working Group
TABLE OF CONTENTS

Page       Contents                                    Page

Section 1 Introduction                                 3

Section 2 Our Vision                                   5

Section 3 Setting the scene                            13

Section 4 The case for change                          21

Section 5 What does the future look like in 2018/19?   31

Section 6 Taking the strategic direction forward       36

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NORTH TYNESIDE URGENT AND EMERGENCY CARE STRATEGY 2014 - 2019 - North Tyneside Urgent Care Working Group
Section 1 Introduction
This section describes how the strategy has been developed and defines what is meant by the term urgent care.

This Urgent and Emergency Care strategy sets out the strategic vision for the
development of North Tyneside’s urgent and emergency care system for the next
five years.

At the heart of this strategy is the need to ensure that every person in North
Tyneside has access to the right treatment in the right place at the right time.

The strategy describes the national and local context, the need for change and the
approach that will be adopted to transform and improve urgent and emergency care
services to address current issues and future needs.

The success of this strategy will be dependent on the commitment of the different
partners and stakeholders to drive the change and improvement needed to
overcome the challenges in our system.

Strategy development

This strategy has been developed by North Tyneside’s Urgent Care Working Group
(UCWG) whose membership includes: North Tyneside Clinical Commissioning
Group (CCG); Northumbria Healthcare NHS Foundation Trust; Northumberland,
Tyne and Wear NHS Foundation Trust; Newcastle upon Tyne Hospitals NHS
Foundation Trust; North East Ambulance Service NHS Foundation Trust; Northern
Doctors Urgent Care; North Tyneside Council; Freeman Clinics; Health Watch;
TyneHealth; and the Area Team of NHS England.

The approach used to develop the strategy has been top down and bottom up. The
top down approach recognises that the strategy has been strongly influenced by the
vision from NHS England’s End of Phase 1 Report 1 that defined five key elements
for future urgent and emergency care services in England. This has been used as a
high level ‘blue print’ for a transformed urgent and emergency care system in North
Tyneside.

The bottom up element incorporates the wider consultation that took place on the
first draft of this document with representatives from the UCWG as well as with the
Project Boards of North Tyneside’s Health and Social Integration Programme. We
will build upon this by engaging with the general public and wider stakeholders on
this document. The final endorsement of the strategy will be sought from the North
Tyneside’s Integration Board.

This strategy will not be implemented in isolation – there are interdependencies with
other local strategies and programmes including:

    •   North Tyneside CCG’s Strategic and Operational Plan;

1
 NHS England (2013), Transforming urgent and emergency care services in England - Urgent and Emergency
Care Review End of Phase 1 Report
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NORTH TYNESIDE URGENT AND EMERGENCY CARE STRATEGY 2014 - 2019 - North Tyneside Urgent Care Working Group
•    North Tyneside CCG’s Long Term Condition strategy and Proactive Care
           programme;
      •    North Tyneside CCG’s New Models of Care;
      •    North Tyneside CCG and North Tyneside Council joint Older Peoples Mental
           Health strategy;
      •    Older Peoples Programme Board;
      •    Better Care Fund Programme; and
      •    North Tyneside’s Integration Programme.

What do we mean by urgent and emergency care?

There is often confusion about the terminology used by patients, providers and
commissioners of urgent and emergency care.

 ‘Emergency care’ is an immediate response to a time critical health care need. A
small number of people suffer from serious illness or have a major injury which
requires swift access to highly skilled, specialist care to give them the best chance of
survival and recovery.

Millions of people have non-life threatening short term illnesses or health problems
for which they need prompt and convenient treatment or advice. Others have pre-
existing health problems, which fluctuate or deteriorate. For many people, when they
have an urgent health need, this can be an emergency to them – “I need some help,
now”.

‘Urgent care’ involves services that are available for the public to access where there
is an urgent actual or perceived need for intervention by a health or social care
professional. These services can be accessed without prior arrangement in-hours; or
these services can also respond when the routine primary care service is unavailable
in-hours.

Good urgent and emergency care is defined as 2:

       •   Patient focussed
       •   Based upon good clinical outcomes
       •   A good patient experience
       •   Timely
       •   Right the first time
Section 2 Our Vision
       •   Available 24/7 to the same standard

2
    RCGP 2011, Guidance for commissioning integrated urgent and emergency care. A ‘whole system’ approach.
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Section 2 Our Vision
This section describes what we aim to do and seven important changes to realise the vision.

North Tyneside’s vision, endorsed by all partners of the Urgent Care Working Group
(UCWG), is aligned with the national vision 3. Our aim is to develop a successful and
long-lasting model of care which supports self-care; helps people with urgent care
needs to get the right advice or treatment in the right place, first time; provides a
highly responsive urgent care service outside of hospital, so people no longer
choose to queue in A&E; and ensures people are treated in specialty centres.

For people with urgent but non-life threatening needs:
   • we should provide highly responsive, effective, personalised services out
      of hospital,
   • deliver care in or as close to people’s homes as possible.

For people with more serious or life threatening emergency needs:
   • we should ensure they are treated in centres with the very best expertise
      and facilities to reduce risk and maximise chances of survival and good
      recovery.

To realise this vision and move to the future system of urgent and emergency care,
seven changes need to happen:

Objective 1            Better support for people to self-care.

Objective 2            Right advice first time.

Objective 3            Responsive urgent care services out of hospital.

Objective 4            Specialist centres to maximise recovery

Objective 5            Connecting urgent and emergency care services together.

Objective 6            High quality and affordable care within the resources available.

Objective 7            Integrating care along the pathway.

The outcome will be an urgent and emergency care system that is able to meet the
needs of the people of North Tyneside: where all parts of the system are integrated
with the wider health and social care economy; makes best use of, and is deliverable
within, the resources available; and delivers improved quality and patient experience.

3
    NHS England (2013), Transforming urgent and emergency care services in England
                                                                                              5
Key Changes
Objective 1: Better support for people to self-care

What does this mean?

   •   Helping individuals and carers to develop knowledge, skills and confidence to
       care for themselves and their health.
   •   Helping people to access the right support, tools and information to manage
       their health problem.
   •   Enabling people to use services appropriately and resources effectively.
   •   Changing the behaviours and perceptions of patients and carers which
       influence how they choose to use the services available.

Key activities:

   •   We will develop a self-care plan which builds upon existing prevention
       strategies across the health and social care system which have the potential
       to impact upon the need for urgent care.
   •   We will work with the local authority and public health teams in their role to
       change behaviour and promote health and well-being.
   •   We will explore how we can better meet information needs and how
       information can be provided regarding self-care for common minor ailments.
   •   We will work with the self-care subgroup of our Patient Forum, support groups
       and other agencies to support and encourage individuals and carers to build
       their capability, capacity and confidence to self-care.
   •   We will raise public awareness of how people can help themselves through
       campaigns such as the Keep Calm campaign and annual health promotion
       campaigns, e.g 2015 Self- Care Week.
   •   We will raise awareness of the range of services provided by community
       pharmacies and how they can help people to self-care particularly for people
       with minor ailments.
   •   We will assess ways for effective communications around self-care, such as
       increasing the use of text messages, email and social media and embed self-
       care messages within other communications where this is possible.
   •   We will develop a social marketing campaign which will segment and target
       patients in order to bring about behaviour change and more effective service
       use.

Success will be:
  • Empowered patients who are more confident to play an active part in the
     management of their own health.
  • People will think self-care first.
  • Patients and carers who know where to find information and advice about
     conditions and treatments and where to go for help when needed.
  • Patients and carers who take responsibility for caring for themselves.
  • A shift in our patient approach from being paternal to facilitative and
     supportive to create a sustainable urgent care system.

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Objective 2: Right advice first time
What does this mean?

   •   Patients and the public will know where to get information and guidance in the
       event of needing to access urgent or emergency care services.
   •   An enhanced, national NHS 111 service which will be the ‘smart call’ to make.
   •   We will ensure we maximise the use of new technologies and media to
       facilitate better access to information and advice about conditions, treatment
       and services.
   •   An urgent care system that is flexible and responsive in how it responds to
       patients and carers.

Key activities:

   •   We will publicise NHS 111 to patients.
   •   We will implement the new national NHS 111 service which will have an
       improved level of clinical input so patients do not need to be directed
       elsewhere when they call.
   •   We will improve right first time patient navigation and better co-ordination
       across urgent and emergency care services through ensuring the NHS 111
       Directory of Services provides increasingly real time information on services,
       their capability and capacity.
   •   GPs and community pharmacists in North Tyneside will work together to
       improve care for their patients. For example pharmacists could take control of
       the management of self-limiting illnesses..
   •   Through the commissioning process we will explore opportunities to increase
       the uptake of new technologies (web- based, mobile phone, and social media)
       so that people can access information about local services.
   •   A whole system approach will continue to be implemented for the sick and
       injured child pathway, which will include training and access in primary care,
       and links to the self-care approach.

Success will be:

   •   Patients and carers will seek advice and treatment for minor ailments that can
       be treated at home or by over the counter medicines.
   •   Patients and carers will know where they can get advice from when they need
       it.
   •   Patients will engage with the care best placed to address their needs.

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Objective 3: Responsive urgent care services out of hospital
What does this mean?
.
  • Same day, every day access to general practitioners and primary care
     services.
  • Harness the skills and accessibility of our community pharmacies.
  • Ambulance service is more than an urgent transport service.
  • Urgent care services at an urgent care centre in the community.

Key activities:

   •   We will integrate pharmacies into the urgent and emergency care system and
       ensure they are marketed as key health services that people choose to
       access.
   •   We will review and reform the current minor ailments enhanced service
       provided by community pharmacies.
   •   We will continue to work with our ambulance trust, the North East Ambulance
       Service (NEAS), to make better use of paramedics’ skills to treat people
       rather than transport them.
   •   We will work with NHS England to ensure there is access to emergency
       dental provision.
   •   We will ensure the Directory of Services is updated so the information that it
       provides is accurate and reflects any changes to local delivery.
   •   The development and implementation of the CCG’s New Models of Care
       should support improving access for patients when they have an urgent
       primary care problem.
   •   We will assume co-commissioning responsibilities to improve primary care
       services locally, including improved access.
   •   We will develop an urgent care centre that will deal with minor ailments and
       injuries allowing Emergency Centres to focus on more serious life-threatening
       conditions; this does not assume it will be a ‘new’ facility. We will work with
       patients, the public, partners and stakeholders on how best to deliver this
       taking the current service configuration, patient behaviours and affordability
       into account.

Success will be:

   •   North Tyneside residents will engage with the care best placed to address
       their needs.
   •   More people will be seen and treated in the community.
   •   People will choose not to go to A&E or be taken to hospital unnecessarily.
   •   There will be no difference in the level of provision regardless of the day or
       time.

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Objective 4: Specialist centres to maximise recovery
What does this mean?

    •   People who have more serious or life threatening emergency care needs
        receive treatment at centres with the necessary facilities and expertise 24/7.
    •   Transformation of a five day model to the delivery of a consistent, high quality
        service seven days a week.

Key activities:

    •   In June 2015 Northumbria’s Specialist Emergency Care Hospital (NSECH), a
        specialised purpose built Emergency Centre, providing high quality care for
        North Tyneside patients with more serious or life threatening emergency care
        needs, will open at Cramlington.
    •   A short stay paediatric unit is planned to form part of the NSECH opening in
        June 2015.
    •   In June 2015, the maternity unit at North Tyneside General Hospital is to
        close with the opening of a new consultant and midwife led unit at the
        NSECH. This facility will complement the existing maternity unit at the Royal
        Victoria Infirmary.
    •   The A&E at The Great North Trauma and Emergency Centre is designated as
        a level 1 Major Trauma Centre; one of two serving the Northern Trauma
        Network.
    •   We will designate the A&E departments at The Great North Trauma and
        Emergency Centre and the Specialist Emergency Care Hospital in
        Cramlington as Emergency or Specialist Emergency Centres in accordance
        with national guidance matching hospital resources to patient acuity and
        complexity.
    •   We will implement the findings of the NHS Services, Seven Days a Week
        Forum 4 through our contracts.
    •   We will review and seek to maximise ambulatory care pathways to ensure
        acute admissions rates reduce.

Success will be:

    •   Recovery from serious of life-threatening conditions will be maximised by
        Northumbria’s Specialist Emergency Hospital in Cramlington and The Great
        North Trauma and Emergency Centre in Newcastle.
    •   Successful delivery of seven day services in urgent and emergency care
        irrespective of the hospital.
    •   Adoption of the clinical standards so there is no difference in the level of
        provision or clinical outcomes delivered in emergency care regardless of the
        day, time or hospital in which the care is provided.

4
 NHS Services, Seven Days a Week Forum: Summary of Initial Findings, December 2013.
http://www.england.nhs.uk/wp-content/uploads/2013/12/forum-summary-report.pdf

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Objective 5: Connecting urgent and emergency care services

What does this mean?

   •   The urgent and emergency elements of the system join up to operate
       together, ‘dissolving’ traditional boundaries between hospital and community
       based services to achieve a consistent approach to service delivery.

Key activities:

   •   We will support the establishment of strategic and operational emergency
       care networks.
   •   We will work with partners and stakeholders members of these networks.
   •   We will support the implementation of the summary care record and
       enhancements to improve the summary care record.

Success will be:

   •   Improved patient outcomes.
   •   Timely access to relevant patient clinical data across the system to support
       good patient care.

Objective 6: High quality and affordable care within the resources
available
What does this mean?

   •   Providing best value for tax payers’ money and using resources responsibly
       and fairly.
   •   North Tyneside CCG in the top 25% of CCGs when benchmarked in terms of
       quality, finance and outcomes measures.
   •   Using evidence based interventions (e.g. NICE guidance).

Key activities:

   •   Through the Better Care Fund Programme Board, we will commit to transform
       the way health and social care is delivered to build a quality and financially
       sustainable future for these services.
   •   We will implement the new commissioning, finance and payment system (tariff
       and incentives structure).

Success will be:

   •   High quality care meeting the urgent and emergency healthcare needs of our
       population which is affordable for the health economy.

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Objective 7: Integrating care along the pathway

What does this mean?

   •   Patients have a positive experience of care which is personalised and where
       they know who is coordinating their care.
   •   Effective working between the individual, community and social care services,
       primary care (in and out of hours) and the ambulance service to ensure
       people are supported in their homes or as close to home as possible.

Key activities:

   •   We will put the individual and their carers’ at the centre of decision making.
   •   We will facilitate timely access to the transfer of information across and within
       health and social care.
   •   We will facilitate effective joint working and streamlined pathways of care
       through the commissioning process to ensure the patient, community and
       social care services work more closely with GPs and the ambulance service.
   •   Through the commissioning process we will develop the workforce to ensure
       the principles of integration are embedded in practice.
   •   By reducing expenditure on hospital services, we will invest in community
       based services to enable people to be cared for without a visit to hospital, as
       set out in Better Care Fund Plan.

Success will be:

   •   Better use of community and social care services.
   •   Removal of unnecessary duplication.
   •   Sharing of information and trust to enhance the patient experience.
   •   Improved patient outcomes.

Expected Benefits

It is anticipated that the strategy will deliver the following benefits:
     • Empowered with skills, knowledge, tools and confidence to self-manage, our
        residents will play an active part in the management of their own health and
        know when to appropriately consult their GP or attend A&E.
     • Hospital when appropriate - improved management of urgent and emergency
        care demand to reduce pressure on the hospital services.
     • Change in patients’ behaviours and how they use services.
     • Improved patient experience – a right first time urgent and emergency care
        system that reduces inappropriate access.
     • Demand for urgent and emergency services will change as patients will self-
        care and have access to responsive urgent care services in the community,
        which they have confidence in.

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•   There will be no difference in the level of provision or clinical outcomes
       delivered in emergency care regardless of the day, time or the hospital.

To ascertain whether the strategy is delivering the anticipated benefits a number of
metrics will be used as indicators of success, which may need to be refined, taking
into account national metrics being developed.

Key Metrics

Key Metric                             Change
Ability to access primary care         Measurable improvements in the ability of
                                       people to access primary care to include: GP
                                       patient survey data; number of patient
                                       consultations; opening hours/clinic hours (GP
                                       access); total number of calls to NHS 111;
                                       number of patients accessing the minor
                                       ailments service.
NHS 111 referral to primary care       Increase of people referred to primary care
services or provided with self-care    and community services against a baseline,
and advice                             such as minor ailments service, urgent care
                                       centre, reduction in referrals by NHS 111 to
                                       A&E due to other alternate disposition.
NEAS conveyance                        Increase in the number of people treated at
                                       the scene against baseline/contract.
                                       Reduction in the number of patients
                                       transported to hospital.
A&E attendances                        Reduction in A&E attendances against
                                       baseline.
Emergency admissions                   Reduction in emergency admissions by 3.5%
                                       in 2015/16
Emergency admissions for               Reduction as new models of care are
ambulatory care sensitive              embedded and people are empowered to take
conditions                             responsibility through self-care/self-
                                       management of their health.

Critical Success Factors
Critical to the success of the strategy include:
    • Commitment of all stakeholders to the strategy.
    • Engagement of public and patients and for them to be at the heart of
        decisions being made.
    • Integration of health and social care provision that increases the proportion of
        people being treated in the community.
    • A collaborative partnership approach between commissioners and providers.
    • Buy-in and leadership across health and social care system.

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Section 3 Setting the Scene
National attention has increasingly focused on the urgent and emergency care system. This section describes
the national and local context within which this strategy has been developed. It outlines that fundamental change
is needed to respond to the needs of an ageing population, the changing burden of disease and rising patient
expectation.

3.1 National context and evidence base

Rising demand, rising expectations, changing burden of disease

The needs of our population have changed since the NHS was established in 1948.
Growing numbers of frail elderly patients, increasing morbidities, more treatable
illnesses and an increased public expectation of healthcare contribute to even
greater pressure on health and social care services.

Our current system of urgent and emergency care is consuming more and more
NHS resources every year. In 2012/13 5 there were:

      •   5.2 million emergency admissions;
      •   6.71 emergency ambulance journeys;
      •   21.7 million attendances at A&E, minor injury units and urgent care centres;
      •   2.7 million calls to NHS 111; and
      •   an estimated 340 million GP consultations.

Since 2010, the NHS budget has been frozen and although the NHS has responded
to the requirement to deliver productivity improvements and progress has been
made, services remain under huge pressure with the increasing demand 6.

NHS England’s Review of Urgent and Emergency Care

In January 2013, NHS England announced the Urgent and Emergency Care Review
(the Review). A steering group was established to develop an evidence base and
principles for the new system. An engagement exercise took place from June 2013
to August 2013. Using the information gained from this exercise NHS England
developed proposals to transform the delivery of urgent and emergency care,
Transforming urgent and emergency care services in England – Urgent and
Emergency Care Review End of Phase 1, published in November 2013.

The report describes the Review’s vision for people with urgent but non-life
threatening needs as well as for those with more serious or life threatening
emergency needs and is a blueprint for local services across the country. The vision
describes five key elements of change that need to happen to move from the current
to the future system:
    • Better support for people to self-care;

5
    NHS England (2013), Urgent and Emergency Care Review – Evidence Base Engagement Document.
6
    The Kings Fund (2014), Priorities for the next government.

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•   Helping people with urgent care needs to get the right advice in the right
           place, first time;
       •   Highly responsive urgent care services outside of hospital so people no longer
           choose to queue in A&E;
       •   Two levels of hospital based emergency centres to ensure that people with
           serious or life threatening emergency needs receive treatment in centres with
           the right facilities and expertise.
       •   The NHS will develop broader emergency care networks, building on the
           success of major trauma networks, to connect urgent and emergency care
           services.

Since the publication of the November report last year, the Review has moved into
delivery phase through an Urgent and Emergency Care Review Delivery Group. In
August 2014, NHS England published a report 7 to update on the Review describing
areas where progress has been, and continues to be made:

       •   Identification of potential sites to test the ideas and models from the Review;
       •   Published, with Monitor, proposals for new payment mechanisms for urgent
           and emergency care services (for 15/16, and beyond);
       •   Published ‘Community Pharmacy’ – helping provide better quality and resilient
           urgent care;
       •   Released revised NHS 111 commissioning standards which reflect the
           Review’s vision and continue to work on piloting arrangements to further
           develop clinical input into the service.

Seven Day Services

NHS services, seven days a week was one of five offers made by NHS England in
the planning guidance published in December 2012 8. The NHS Services, Seven
Days a Week Forum 9 (the Forum) was subsequently established and asked to
focus, as a first stage, on urgent and emergency care services and supporting
diagnostic services.

The Forum’s review pointed to significant variation in outcomes for patients admitted
to hospital at weekends across the NHS. The variation is seen in mortality rates,
patient experience, length of stay and re-admission rates. A set of 10 clinical
standards, describing the standard of urgent and emergency care that patients
should expect to receive seven days a week, were developed by the Forum to be
enacted through contracting in 2014/15.

Urgent and emergency care was also one of the priorities in the planning guidance,
issued to commissioners in December 2013, to support the two and five year
planning process 10. The Review ensured that this planning guidance contained
information to stimulate commissioners’ thoughts as to how they should deliver the
vision envisaged in the End of Phase 1 Report, including treating patients as close to
7
  NHS England (2014), Transforming urgent and emergency care services in England: Update on the Urgent and
Emergency Care Review
8
  NHS England (2012) Everyone Counts: Planning for patients 2013/14
9
NHS England (2013), Seven Days a Week Forum: Summary of Initial Findings
10
     NHS England (2013), Everyone Counts: Planning for Patients, 2014/15 to 2018/19

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home as possible and preparing the way for the establishment of the urgent and
emergency care networks.

Five Year Forward View (FYFV)

Published by NHS England in October 2014, the Five Year Forward View 11 is
consistent with the Review’s vision for urgent and emergency care services and
highlights six priority areas:
   • An upgrade in prevention and public health;
   • Greater control for the patient over their care;
   • Radical new care delivery models – multispecialty community provider model
       and primary and acute care systems model;
   • Integrated urgent and emergency care services;
   • Greater control by CCGs over the wider NHS budget; and
   • A balance of demand, efficiency and funding.

3.2 Our local context

Whilst there are national drivers for change, this strategy must address local needs
as well as take into account local priorities, existing urgent and emergency care
resources and programmes of change.

What are the challenges for North Tyneside?

       •   Ageing population with increasing needs;
       •   Health inequalities between localities in North Tyneside;
       •   Higher and increasing use of hospital based services (e.g. elective and urgent
           admissions);
       •   Demand for resources are outstripping those available therefore high impact
           interventions are needed if the health economy is to be sustainable in the
           future;
       •   Minimal growth in financial allocations and funding to shift to social and
           primary care.

Population and Demographics

We serve a population of 215,602 12, which is projected to grow by 9.8 per cent by
2030 with an increasingly ageing population. It is forecast that the number of
people aged 65 years and over will increase by 35%, from 37,836 in 2013 to 51,000
in 2030. It is also estimated that the number of people aged 85 and over will increase
by 100 per cent between 2013 and 2030 to 7,000 creating additional demand for
social care, housing and health services.

11
     NHS England (2014), Five Year Forward View
12
     As of October 2013

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The number of children and young people is projected to grow by 9.4 per cent by the
year 2030, with the biggest increase in the four to nineteen age group.

North Tyneside is made up of coastal areas in the east (Whitley Bay, Cullercoats and
Tynemouth), towns (North Shields and Wallsend) and some rural areas, such as
Backworth and Earsdon. Within North Tyneside, Wallsend and North Shields there
are areas that would be considered to have the highest levels of deprivation,
although there are also pockets of high deprivation in the other localities.

Although the borough of North Tyneside is now one of the least deprived in the North
East, stark inequalities persist within the borough. The relationship between social
deprivation and ill health has long been recognised. People living in areas with
higher levels of deprivation tend to have poorer health than those living in more
affluent areas.

We have examined the relationship between social deprivation and the rate of
attendance at Accident and Emergency (A&E) units and a link is well established.
From our analysis, we conclude that social deprivation is a strong indicator of the
probability of going to A&E but less of a strong indicator of the probability of going to
A&E with a condition which could be managed in other ways – for example, self-care
or routine GP appointment.

Health Profile

North Tyneside has above average levels of need across a range of diseases and
conditions (hypertension, coronary heart disease, diabetes, chronic obstructive
airways disease and cancer) particularly in its most deprived communities. A growing
elderly population and lifestyle choices (smoking, alcohol and obesity) are adding to
the burden on health resource.

The Joint Strategic Needs Assessment (JSNA) has been developed and is the
starting point for developing health and wellbeing strategies and underpinning
commissioning decisions. This strategy draws upon the following key messages from
the JSNA:

   •   Long term conditions and dementia will be among our biggest challenges
       going forward.
   •   The proportion of people with a disability is also likely to increase with an
       ageing population creating additional demands for service provision.
   •   The economic downturn and the current welfare reforms are affecting the
       income of residents with the inevitable consequences for their health and
       wellbeing.
   •   The principal cause of premature death in North Tyneside is cancer, followed
       by cardiovascular disease.
   •   Poor mental health and wellbeing in parts of the borough are inextricably
       linked to socio economic deprivation and vulnerability.
   •   Alcohol is the second biggest lifestyle risk factor after tobacco use. Alcohol
       misuse is a major problem within North Tyneside in terms of health, social and

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economic consequences which affect a wide cross section of the borough at a
       considerable cost.
   •   One in five children and young people live in poverty in North Tyneside.

Our local health system

Northumbria Healthcare NHS Foundation Trust (NHCFT) provides most hospital
services for North Tyneside residents. Since 2011, community health services for
North Tyneside residents have been provided by NHCFT.

Although Newcastle upon Tyne Hospitals NHS Foundation Trust (NuTH) provides
services for residents predominantly in west North Tyneside, this is not the case for
specialised and maternity services.

Both hospital trusts have an Accident and Emergency department. NHCFT’s A&E is
situated at North Tyneside General Hospital however this will change in June 2015
when Northumbria’s Specialist Emergency Hospital will open providing care for the
500,000 population of North Tyneside and Northumberland. This will be the first
hospital to be built in England dedicated to treating seriously ill or injured patients
separating the emergency work from elective which will be delivered at three general
hospitals: North Tyneside, Wansbeck and Hexham General Hospitals.

NuTH’s A&E is located at the Great North Trauma and Emergency Centre in
Newcastle. The Great North Trauma and Emergency Centre is one of two regional
Major Trauma Centres and also provides eye casualty for eye emergencies.

At the time of developing this strategy it is unclear whether the designation of our
current A&E departments, provided by NuTH and NHCFT to Emergency
Centre/Specialist Emergency Centre will be for local determination or nationally
defined. Discussions will need to be held with our hospital providers.

Primary care services are provided by 29 GP practices, 30 NHS dentist practices, 20
optometry practices and 51 pharmacies. We have a walk-in centre provided by
Freeman Clinics and GP out of hours is provided by Northern Doctors Urgent Care
(NDUC).

North East Ambulance Service (NEAS) provide NHS 111 services in addition to
being our ambulance provider. Our mental health services are provided by
Northumberland, Tyne and Wear Foundation Trust. NHCFT provides Psychiatry of
Old Age Services, Taking Therapies and Children’s Adolescent and Mental Health
Services.

We also commission a range of services from the independent and voluntary sector.

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3.3 NHS North Tyneside CCG’s Commissioning Plans

Five Year Plan: 2014/15 to 2018/19

In 2014, a draft North Tyneside Strategic Plan (the Plan) was developed jointly with
the Council, providers and other stakeholders covering the period 2014/15 to
2018/19. This plan is the first five year strategy produced by North Tyneside CCG
and a number of key strategic objectives have been identified help to achieve the
CCG’s Vision: Working together to maximise the health and wellbeing of North
Tyneside communities by making the best possible use of resources.

This is represented by the following diagram.

Existing and emerging programmes and projects that are already taking place and
that are complementary to and support the aims of the strategy are described below.

Keeping Healthy and Self-Care

In North Tyneside, the CCG is developing its health and social care system so that it
is more focused on preventing ill health and maximising wellbeing and becoming
less reliant on reactive care services; this will reduce demand for urgent and
emergency care. Central to this is commissioning services to promote and enable
people to self-care.

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Self-care is about individuals, families and communities taking responsibility for their
own health and well-being. It includes actions people take to stay fit and maintain
good physical and mental health, meet their social and psychological needs, prevent
illness or accidents and care more effectively for minor ailments and long term
conditions.

The CCG’s overall strategy for long term conditions is to improve care outside
hospital, starting from earlier diagnosis and management in primary care, and
supported self-care. Improved management of long term conditions through
proactive care and support has the potential to reduce the impact and flow of
patients into emergency and urgent care. Improved patient knowledge and inclusion
in the design of their care package and the joining up and integration of services
should deliver these benefits as people are cared for longer in their local
environment rather than being admitted to hospital.

Caring for people locally - new models of care

We plan to adopt the ‘extensivist model’ of care in North Tyneside which provides
pro-active care planning and co-ordinated care wrapped around the patient with a
single point of access. We will identify patients with multiple, complex conditions in
our population deemed to meet the moderate to severe scale on the frailty index and
commission an extensivist’ service to co-ordinate care to meet specific needs so that
their conditions are managed to the best possible extent and their wellbeing is
maximised. This approach will reach out to around 30% of our population and will
reduce patient need for reactive hospital services.

By caring for the most complex patients through this model we will make available
additional capacity within primary care to provide improved care for patients with a
single chronic health issue. Improved care for these patients will further reduce our
reliance on reactive hospital services releasing further funds to commission
alternative services.

We will create primary care hubs where practices work together to provide primary
care at scale, creating better local relationships between people and care providers
and integrate the extensivist model into the hubs.

Two Year Operational Plan

The CCG’s two year operational plan was developed for 2014/15 and 2015/16 and
forms the basis for implementing our strategic plan. Urgent care is one of the CCG’s
3 priorities for this two year plan.

The stated ambition is to reduce emergency hospital admissions by 15% between
2014/15 and 2018/19, of which a 3.5% reduction is required in 2015/16. The latter is
to enable a shift from hospital to primary, community and social care services
through the Better Care Fund, and will be facilitated through a number of schemes.

Our Better Care Fund Programme is illustrated below

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Section 4 The case for change
A key objective of this section is to set out the drivers for change – including patients’ insight, patients’
expectations, our ageing population, increasing demand, limited resources –and explains why we need to take a
different approach in the future to address the challenges.

4.1 Engagement, Listening and Feedback

The CCG engaged with the public in September and October 2013 to discuss how
the CCG plans to invest in health from 2014/15 onward. Key messages, specific to
urgent care, that emerged included:

             •   Access to primary care appointments at GP practices
             •   Confusion around who to contact for urgent care in and out of hours
             •   Concerns over the new Specialist Emergency care Hospital in terms of
                 transportation and ambulance response times
             •   Greater education on self-management of conditions, minor illnesses
                 and following recovery from illness

Patient Insight

We have established a patient forum (the Forum) as a sub-group of the CCG’s
Governing Body as a way of engaging with the public and listening to feedback. We
shared the key issues and themes with the Forum that emerged from a review of the
significant insights we have gained into patients’ needs and wishes on a range of
urgent care issues over the past ten years. The Forum prioritised the themes to
reflect the importance they place upon them.

Figure 1 below visually depicts the view about about the priority that should be
assigned to the elements of the urgent care system. For them, access to the NHS
seven days a week is central and everything revolves around this starting with GP
practices at the top going clockwise 360 degrees.

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GP practices

                                999                       NHS 111
                             ambulances                   service

                   Self care
                                             NHS
                 looking after            services 7                 Out of hours
                   yourself
                                            days a                   GP services

                                            week

                                                                                    Figure 1
                                 A&E                      Pharmacy

                                            Walk in
                                            centres

Themes              What the patient forum said

7 day services      7 day services were welcomed as the NHS needs to mirror
                    modern life.

                    The main message for 7 day working was a wish to have GP
                    access 7 days a week, filtered through NHS 111 if necessary.

                    It was felt GP telephone appointments should become more
                    routine.

                    It was felt that there is a need to ensure all extended working is
                    aligned across the whole health and social care system.
GP practices        The strongest message was that people felt they had a strong
                    relationship with GPs and their GP would be the first choice for
                    the majority of ill health in the main.

                    Access was an issue – including telephoning the practice at
                    8.30am; appointments in the early morning, evening and
                    weekends; contacting the practice on Monday morning especially
                    if you have been ill over the weekend.

                    More flexible appointments were requested
                    (evenings/weekends) to fit in with people’s busy lives and not
                    necessarily with your own GP practice as long as it was within
                    your local area.

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Concerns about GP premises – DDA compliance.

                  Supported as a concept - an easy to remember number to help
                  with urgent needs and direct to local services.

NHS 111           Key message was a lack of awareness about NHS 111 –
                  people were unaware that the GP Out of Hours service is
                  accessed through NHS 111. Publicity is needed.

                  It was felt that the public needed to be educated to understand
                  NHS 111 better and what it is there to do.

GP Out of hours Need to promote how to access GP OOH through NHS 111.
                A choice of venues and for those, unable to leave home, to be
                seen by an OOH doctor at home.

                  There was confusion about getting prescriptions dispensed out of
                  hours.

Pharmacy          Promotion of the pharmacist as ‘expert’ and helping people to
                  understand pharmacists are not ‘shop keepers’.

                  It was felt to be an under used resource but has great potential
                  with the right promotion acknowledging:
                      • Public perception - some people might feel that being
                         advised to see the pharmacist was being ‘fobbed off’.
                      • Limitations of the pharmacist if the health condition is
                         serious and what action the pharmacist could take

                  Think Pharmacy First was supported but better awareness of
                  this is needed, particularly by GP practices and for the practices
                  to signpost to pharmacies. The problem with it however is that it
                  is means tested.

Walk-in service   There was a strong feeling that walk-in services are used so
                  much as they offered convenience, especially if quick
                  appointments were unavailable with the GP.

                  Geographical access is the most important factor and
                  accessibility on foot/public transport/car and free car parking.

                  There was confusion about what services are available at a
                  walk-in service.

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Main issue was to be reassured that there would be the ‘right
A&E                 staff’ at North Tyneside General Hospital A&E department when
                    the new hospital opens at Cramlington.

                    There was concern about patients who ‘boomerang’ back into
                    A&E – high risk patients and those at risk of re-admission.

                    There was a strong message for the need to discharge at
                    appropriate times with support in the community.

                    Issue of car parking charges – expensive and unnecessary.

Self-care -         Guidance, local information and sign posting should be up to
looking after       date and where people can find local help and advice on ‘how to
yourself            look after themselves’.

                    There should be on-going campaigns on television/radio to
                    constantly remind people about self-care.

                    Key in this is the word self-care and what it means.

999 ambulances Key message was not being sure if 999 was needed however
               there was a view that people’s perceptions cannot be easily
               changed.

                    Generally it was felt that ambulance services were good and
                    paramedics were responsive and well qualified.

Patient surveys

In April we interviewed 62 patients attending Battle Hill walk-in service. In May and
June 2014, a survey was carried out of 69 patients who were attending North
Tyneside General Hospital A&E department. Interviews were carried out during
morning, afternoon and evening sessions including the weekend.

From the engagement work at both the walk-in service and A&E, we know that
convenience is a key criterion – close to their home and easy to get to - and most
travel less than 10 minutes to get there.

However of those surveyed at Battle Hill, only 50% described their condition as
urgent.

61% (n=42) of those surveyed at A&E believed their condition was urgent and
requiring immediate attention. For almost a quarter (n=14), this was their first visit to
North Tyneside General A&E however 50.5% (n=35) had been to A&E between 2
and 12 times and 12% (n=8) had visited A&E more than 12 times. This could
suggest that that A&E is the ‘default’ in absence of suitable alternatives for patients
                                                                              24 | P a g e
however 45% of A&E attendances took place during the hours of 08.00 and 18.00
when GP practices and alternative services are available. It may be more
symptomatic of inappropriate use of a resource which is for serious and life-
threatening conditions.

Based upon what patients reported, attendances at A&E were for cuts, bruises or
abrasions, eye/ear infection and stomach ache. The main reasons were sprain or
strain and suspected fracture/broken bone. However the greater number of
attendances at Battle Hill walk-in service was for minor ailments, such as coughs,
cold and sore throat, eye/ear infections and skin conditions, than minor injuries.

People attending Battle Hill reported that they did not contact their GP practice as
they believed that they would be unable to get a GP appointment. The majority did
not consider alternative services, for example ringing NHS 111, going to a pharmacy.
The majority of people going to the walk-in service fell into two age categories: 25
years or younger; and aged between 35 and 44

It is hard to quantify the number of people who go to A&E because they think they
will not be able to get an appointment with their GP whether this is actually the case
or not. Only 16% (n=11) had contacted their GP practice before attending A&E and
of these less than half (n=4) were advised to attend A&E.

4.2 Increasing demand

Demographics

Our local population is growing year on year and it is anticipated that this increase
will lead to an increased demand on all health and care services, including hospital
services.

The number of children aged between 0 and 14 is projected to grow by 10 per cent
by 2020.

A&E attendances in children and young people aged 0 -18 accounts for around a
fifth of all attendances.

Although similar to the population of England with an increasing ageing population,
North Tyneside has a slightly higher proportion of people aged 65 and over. Much of
the growth will consist of people aged 65 and over, who make greater use of hospital
services than younger people. It is estimated that by 2020 the number of people
aged 65 and over will increase by 16 percent and the number of people aged 85 or
over will increase by 24 percent. The greatest increase is projected in the number of
people aged 70 to 74 and over 90.

An ageing population will increase demand for urgent care. People over the age of
65 accounted for around a quarter (24.2 per cent) of all A&E attendances in 2013/14.

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The table below sets out what we know about our current population, the current
number of emergency bed days, the projected population in 2030 in order to
understand the numbers of additional hospital bed days that would be required by
2030 if existing patterns of use of hospital services remain unchanged.

A          B            C               D           E            F             G             H

                                        Emergency                              Projected     Additional
                                        bed days,                Projected     additional    emergency
           CCG                          per 1,000   Projected    emergency     emergency     beds needed
           Population   Emergency bed   persons,    population   bed days in   bed days in   at 100%
Age band   2013         days, 2013/14   2013/14     2030         2030 (D*E)    2030          occupancy
                                                                               -
0-65       176,546      40,692          230         167,300      38,560        2,132         -6

65-74      20,182       26,368          1,307       27,000       35,275        8,907         24

75-84      13,461       46,239          3,435       18,900       64,922        18,683        51

85+        5,202        47,477          9,127       8,100        73,926        26,449        72

TOTAL      215,391      160,776                     221,300      212,683       51,907        142

This calculation projects that emergency bed days will increase by 38 per cent from
£160,000 in 2013/14 to £221,000 in 2030; this would fill an additional 142 hospital
beds every day of the year.

Patient Behaviour

The growth of the demand for urgent care has increased despite better access, such
as the walk in service and extended GP hours.

Our local information shows that urgent and emergency services are being used in a
way that we did not expect. People are visiting the walk in service for conditions
(coughs, colds and sore throats) that are treatable at home or with over-the counter-
medicines from a pharmacy. People prefer to go to the walk-in service for minor
ailments rather than going to a pharmacy or calling NHS 111.

People are also continuing to attend A&E for minor ailments rather than going to the
pharmacy, using the walk-in service or their GP practice.

Battle Hill walk-in service

This service was introduced as an alternative to A&E and was intended to relieve
pressure on A&E by helping to provide capacity and decrease the need for A&E to
see patients with minor conditions.

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Locally there has been an increase in the number of people attending the service at
Battle Hill without the anticipated decrease in the numbers at A&E. In fact
attendances continue to rise.

People generally like the walk-in service and it has helped improve access to primary
care by making NHS services more responsive to people’s busy lifestyles as it is
open 08.00 to 20.00, seven days a week, 365 days a year.

The service commenced in August 2009 and its contract is due to expire in August
2015. It was originally contracted to see 14,000 people a year. The box below shows
how activity has increased.

Battle Hill Walk in service activity levels:

 2010                    19,536
 2011                    24,672
 2012                    30,490
 2013                    33,694

Accident and Emergency (A&E)

A&E is the focus of much media and political interest. Many patients presenting to
A&E or calling 999 do not need the specialised care offered by these services and
would be better served elsewhere. From patient engagement work, patients
attending A&E seem unaware of the options available, such as NHS 111 and
pharmacies.

There has been a growing number of attendances at A&E in England. There were
21.8 million attendances at A&E in 2013-14; 32% higher than ten years ago.
However attendance at major departments has grown by just 12% since 2003-04
indicating that the bulk of growth in A&E attendance is due to the introduction of
more minor A&E departments such as minor injury units. 13

In the calendar year 2013 there were 68,592 A&E attendances; 51,056 were seen
and treated at North Tyneside General Hospital and 15,523 at A&E at the Great
North Trauma and Emergency Centre. Attendances at A&E for North Tyneside
residents have fallen slightly.

                 2011        2012         2013         Variance
 NTGH            52,727      53,476       51,056       -4.5%
 NuTH            13,994      15,833       15,523       -2.0%
 Total           68,732      71,321       68,592       -3.8%

A ‘surge’ in A&E attendances during the winter months does not appear to be a
feature in North Tyneside as analysis shows summer months are as busy as
December to March.

13
  Accident & Emergency Performance. England 2014/14:national and regional data. Research Paper 14/22, 14
April 2014

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We know that most urgent care needs are not life-threatening and many of the
patients go to A&E instead of seeing their GP or an alternative service. Of the 68,592
patient attendances at A&E, 12% (n= 8,231) of the patients, didn’t need any
treatment at all; they were given verbal or written advice and assurance.

Of all children going to A&E 14 per cent left with no treatment or investigation having
been undertaken and this was higher (15%) for very young children (0 to 4 years).
This may reflect an attendance due to parental anxiety.

Risk aversion may be contributing to the pressures experienced by the urgent and
emergency care system. For example, a parent or carer will take a child directly to
A&E rather than wait for an appointment with a GP or a patient may be conveyed to
A&E when they could be treated in an alternative setting. This is a complex issue
and is related to the way people perceive and respond to risk, assess the potential
seriousness of a particular condition, confidence in decision making and options that
are available to them.

Pressure on A&E services

The government asks that no one waits longer than four hours to be seen in A&E
and both our hospital providers (Northumbria Healthcare NHS Foundation Trust and
Newcastle upon Tyne NHS Foundation Trust) have consistently performed well to
this NHS standard. However, the continued achievement is a concern for both our
hospital trusts due to pressures on A&E services.

Increased demand for GP consultations, patient frustration at booking appointments
(how quickly you can get through to the practice by phone and discontent with
getting appointments) may drive people to seek alternative services. This can result
in A&E as a ‘default’ especially as patients know they will always be seen and will
have to wait a maximum of four hours.

We also know from analysis of patients’ attendances at A&E departments and their
ward of residence along with our survey of patients attending A&E that for some the
proximity of the service is a major consideration that influences their choice.
Those living close to an A&E department or the walk-in centre tend to use these as
an alternative to seeing their GP.

As a result of people using A&E for minor ailments, waiting times increase in A&E as
these patients are likely to have to wait a longer time to be seen treated and
discharged while emergency cases are being prioritised.

4.3 General Practice – access, convenience and
responsiveness

The GP practice is the first place that most people go when they have a health
problem. Nationally about a 100 million same day appointments are made across

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9,000 practices across England, about a third of the overall visits to practices in a
year 14.

There are currently 29 practices in North Tyneside. GP access is challenging to
assess as the Area Team, who commission General Practice, do not have any
metrics to determine if a practice has access issues. The metrics that are available
relate     to  patient   surveys    at   practice   level  and     are    published
at http://www.primarycare.nhs.uk

The three relevant metrics for access are:
   1. Patient experience
   2. Getting through by phone
   3. Making an appointment

Whilst general practices are just one element of primary care they are the preferred
and generally the first port of call for most people seeking urgent care and receive
high satisfaction ratings 15.

An ageing population with more complex needs and increasing number of long term
conditions is leading to increasing demands on GPs. One of the consequences of
this increased demand for consultations is patient dissatisfaction with access to their
GPs. From our patient engagement, there are concerns about getting access to a
GP and many people find the availability (opening times) inconvenient as it coincides
with their normal working day; people want more flexible appointments including
access to general practices seven days a week.

4.4 People’s expectations
People’s expectations of what they should receive from a service are also changing
rapidly. Technology and the move to a 24/7 lifestyle mean that increasingly people
expect 365/24/7 access to services, to be able to see who they want, when they
want at a time and place convenient to them. We know from our surveys of patients
attending Battle Hill walk-in centre service there is a cohort of patients who prefer to
be seen quickly; speed is prioritised over the setting they are seen in.

4.5 Data sharing
Information sharing between different elements of the urgent and emergency care
system is compromised due to systems’ interoperability. This can result in patients
being taken to A&E as a risk averse default position when other appropriate options
would allow treatment in situ.

4.6 Financial environment

14
     http://www.primarycarefoundation.co.uk/urgent-care-in-general-practice.html
15
     http://www.gp-patient.co.uk/

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We know that changes in demographics, particularly a growing proportion of older
people is driving up demand for and overall cost of healthcare. Increasing life
expectancy is a contributory factor as well.

This growth in demand is taking place at a time of austerity which continues to put
pressure on NHS funding and current forecasts point to a £30bn gap in funding by
2020/21.

Finances are not the most important consideration but we need to understand that
the local NHS now has less money than it did in previous years. For North Tyneside
this means we need to review where we spend our money and what outcomes are
achieved in order to ensure we are getting the best quality and value services for our
patients.

Commissioning high quality affordable healthcare is one of North Tyneside CCG’s
strategic priorities in our two year operational plan for 2014/15 to 2015/16. A
strategic principle that guides our approach to commissioning services is: Best
value for taxpayers’ money and using resources responsibly and fairly. The
average cost of accessing urgent and emergency care varies considerably
depending on how and where it is accessed. We have a budget in 2014/15 of £287m
to ensure that 215,391 people of North Tyneside have access to the right healthcare
services and the urgent and emergency care system and the way services are
delivered must contribute to this strategic priority.

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